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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Manteca, CA PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V& W Drillin IDSC. <br /> License#: 720 04 Expiration Date: 4/30/2020 <br /> Signature: AMU Title: Presidept <br /> Print Name: Karli Renae Stroin Date:_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: State Fund — Policy#: 9115022-18 _ Exp. Date: 10/2/2019 <br /> I certify that in the performance of the 4, which this permit is issued, I shall not employ any person in <br /> any manner so as to becomesubje to the ork ' compensation law of California, and agree that if I <br /> should become subject to workers' mpe abo pr visions of Section 3700 of the Labor Code, I shall <br /> forth 'th cbmpl wit those provisions. <br /> Signature: <br /> Print Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Kadi Renae Stroing , he y au orize Condor Earth Technologies <br /> FG QF.of Audwdd Agam <br /> to sign this San Joaquin County Well "oring P rmit pli do on my behalf. I understand this <br /> authorization is valid for one y r di II d to the ork plan ate on the front page of this application. <br /> t <br /> of C47—7 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />